CORE MEASURES

2009

What are “core measures”?

• Patient groups where there is significant agreement regarding evidence-based medicine

• Defined by CMS and Joint Commission

• An expectation that we will follow specific ‘best practice’ guidelines in our treatment of every patient in these diagnostic groups

Which Patient Groups Are “Core Measures”?

• CHF- Congestive Heart Failure

• PNE- Community Acquired Pneumonia (previously called CAP)

• AMI- Acute Myocardial Infarction

• SCIP- Surgical Care Improvement Project

• PSYCH- Psychiatric measures (our choice to use these as ‘best practice’)

• ALL – Patient Satisfaction. See module!

What Is Expected?

• There are specific treatment requirements for each of these patient groups.

• We audit 100% of patients’ charts, for those patients in these groups. We then submit our data to CMS and Joint Commission.

• All hospitals nationally participate in this process.

• Results are compared among hospitals and published on the internet.

What Is the Key to Improvement?

• Identify these patients as early as possible in their care. – Nursing, physicians, admissions and case

management all can make this identification. (Note in both StatCom and EPIC. )

• Protocols! – Our physician partners have agreed on specific

protocols for each of these patient groups.

• Multidisciplinary teams: – Address the care these patients receive from admit to

discharge.

• Increased, prompt awareness of these patients

Why Do We Do This?

• Evidence shows that these measures:– Minimize hospital length of stay– Prevent development of microbial resistance– Reduce mortality, morbidity– Reduce hospital costs

• It’s the right thing to do!

2007, Up To Date ® Thomas M. File, Jr. MD

Summary of Forms• AUDIT TOOL: Core Measure Check List• Pneumonia protocol (4 page order set)• CHF protocol (in development as of 8/07)• CHF physician discharge checklist• Revised medication reconciliation form• ACS protocol (all AMI & angina patients- 8/07)• ACS physician discharge checklist• Revised orthopedic surgery protocols• Revised VTE prophylaxis form

Tools to Use in Treating

Congestive Heart Failure

What Kind of Tools?• Heart Failure Order Set

• Medication Reconciliation form – • The physician MUST SIGN the medication

reconciliation form for ALL CHF patients.

• Physician Discharge Planning Progress Note for CHF Hospitalization.

• The physician must complete this form prior to discharge

• New reminder sheet for nurses!– A prompt and audit tool, ALL IN ONE!

How Do I Get Started?

• Obtain the Medication Reconciliation Form and place it on the chart for the physician to sign at discharge – Form # 81011

• Place the Discharge Planning Progress Note for CHF Hospitalization on the chart– Form # 7680 (10/07)

• Inform Physicians that these forms are available and where they’ll be stored

IT’S UP TO ME TO IDENTIFY THE CHF PATIENT?

• Yes, particularly if the diagnosis is not immediately noted on admission.

• Clues to look for:– History of heart failure– Was the patient admitted for shortness of breath or

edema ?– Did the patient receive any IV diuretics ?– Does the patient have and implantable cardiac

defibrillator (ICD) or biventricular pacemaker

• There is a CHF decision tree to help assist.. See your Clinical Educator.

What Are the Requirements?

• For CHF patients, we must1.Accurately identify these patients and

implement the CHF teaching tool 2.Give the patient a copy of the Discharge

Declaration Sheet prior to discharge.3.Obtain physician signature on the medication-

reconciliation form for ALL CHF patients.4.Physician must complete the Discharge

Planning Progress Note for CHF

Hospitalization.

Tools to Use in Treating

Community Acquired Pneumonia

How Do I Get Started?

• Place the Pneumonia Order Set on the chart– Form #7900-005 (it’s four pages)

• Inform Physicians that the form is available and where it is stored

• Become familiar with the orders

• Implement them promptly

What Kind of Tools?• New name for CAP!

– CAP has a new acronym: PNE or PN

• New Protocol!– The “Community Acquired Pneumonia Order

Set” simplifies admission orders for these patients

• The audit sheet helps to cover all key points!

What Are the Requirements?

• For PN patients, we must:– Obtain blood cultures x 2; chart when collected– Start antibiotics within 6 hours of arrival (time the

patient arrives, not the time of admission) – Give first antibiotic ASAP & after blood cultures are collected

– Assess pneumonia and flu vaccine status and administer if indicated – Pneumoccal vaccine for patients >64 years, year round. Influenza vaccine for patients > 50 (October 1 through March 31)

Tools to Use in Treating

Acute Coronary Syndrome

(All AMI & angina patients)

AMI & ACS

• ATTENTION CATH LAB AND ED• 90 minutes from “ED Door” to PCI!!• This applies to all STEMI patients (if you have a

question, get the protocol!)• Time is measured from arrival, not admission, to

time of PCI (first inflation)• Increases survival rates• New protocol for care and discharge elements

for all acute coronary syndrome patients

How Do I Get Started?

• Use the ACS Order Set/protocol

• Inform Physicians that this order set is available and where it will be stored

• Become familiar with the orders

• Implement them promptly

Important Tools to Use in Treating

The Surgical Patient(SCIP…Surgical Care Improvement Project)

Key Documentation for All Surgery Patients

• The correct antibiotic and means of administering it

• Accurate surgery start time

• Accurate surgery end time

• Clinical trial participation: yes/no

• Signs/symptoms of infection prior to procedure

Which Surgical Inpatients?

• Hysterectomy

• CABG

• Other Cardiac Surgery

• Colon Surgery

• Hip and Knee Arthroplasty

• Vascular Surgery

Principal procedure only

ANTIBIOTIC MANAGEMENT

• #1 Right antibiotic selected

• #2 Right Pre-Op Time - To START

• #3 Right Post-op Time - To STOP

• PRE-OP Nurse’s Role:• Send the ordered antibiotic to the OR

so it may be hung at the correct time (one hour prior to the surgical incision as

Administered by anesthesia)

ANTIBIOTIC MANAGEMENT

• POST-OP Nurse’s Role:• Discuss with PACU RN if antibiotic order

states administration time frame exceeding 24 hours and the reason for extension

• IF time frame not stated in the order, ask the PACU nurse to state the surgical END time and document the END TIME on the MAR. Also, include this information during shift report.

• Night shift to carry this END TIME to 1st day post-op MAR (1st and 2nd day post-op MAR for the cardiac surgical patient)

ANTIBIOTIC MANAGEMENT

• 1st DAY POST-OP Nurse’s Role:

• Obtain an order to continue antibiotics greater than 24 hours post-op – (48 hours for the cardiac surgical

patient)

• Order must include an indication for the lengthened administration time For Example: History of MRSA

VTE PROPHYLAXIS

• Applies to ALL post-surgical patients

• OR staff to place the VTE Prophylaxis Order sheet on the medical record and recommend physician complete PRIOR to the patient leaving the operating room

• Risk factors selected by physician:• One risk factor = LOW VTE RISK• Two – Four risk factors = MODERATE VTE RISK• > Four risk factors = HIGH VTE RISK

VTE PROPHYLAXIS

• VTE prophylaxis interventions are selected based on the RISK LEVEL

• Immediate post-op receiving nurse, to review VTE Prophylaxis Order sheet and implement interventions selected by the physician

• Sign off the order

• During “hand-off” report to unit nurse, discuss RISK LEVEL and VTE prevention interventions already implemented.

VTE PROPHYLAXIS

• VTE prophylaxis MUST BE re-assessed AND a NEW form completed at the following points during the hospital stay:

• WITHIN 24 hours of admission• Post-operatively• PRN• From transfer from one level of care to

another• MAKE THIS PART OF YOUR HAND-OFF

REPORT!

Which Surgical Outpatients?

• Cardiac

• Orthopedic

• Genitourinary

• Gastric/Biliary

• Gynecological

• Head and Neck

• Neurological

Elements for Outpatients

• Choice of antibiotic

• Timeliness of antibiotic

• Clip don’t shave

ADDITIONAL TOOLS• Appropriate hair removal

• Post-operative serum glucose control

• Perioperative beta blocker for patients on beta blocker prior to surgery

New Tools to Use in Treating

Psychiatry Inpatients

What are the requirements for admission screening?

• Must be performed within 3 days of admission

• Psychiatric Evaluation screening of:– Patient Strengths– Psychological Trauma History– Violence Risk to self and others over the past

6 months– Alcohol/Substance Abuse over the past 12

months

What are the requirements for discharge information?

• The Brief Referral Summary is used to document key discharge information.

• The Brief Referral Summary must contain the:– Discharge diagnosis– Reason for hospitalization– Aftercare recommendations– Evidence that the form was sent to the next level of

care provider by the 5th post-discharge day

What are the expectations for patients discharged on multiple antipsychotic

medications?

• Discharge medications need to be documented on the Medication Reconciliation Form

• If patients are discharged on two or more antipsychotics, documentation on the Brief Referral Summary of:– A history of a minimum of three failed trials of monotherapy– A recommended plan to taper to monotherapy due to previous

use of multiple antipsychotic medications OR documentation of a cross-taper in progress at the time of discharge (meds to increase and decrease must be documented)

– Augmentation of Clozapine

Final Outcome?

• Core Measures are standards of care that improve patient outcomes.

• Each of us plays an important role in bringing these care standards to the patients that require them.

• 100% is the only percentage that is acceptable!

• Is your patient covered??

Key Points!

• Question: When do we use core measure protocols and other tools? – Answer: When the patient arrives at the hospital

• Q: Which patients require screening for core measures? – A: Every one of them. All.

• Q: At what point are core measures resolved? – A: At discharge, when patient teaching is complete,

and the Med Rec form has been faxed to the next provider of care or entered into EPIC.